NCLEX-RN&CGFNS真題解析-priority&first action 3
A clinical nurse received four phone calls from discharged clients
as following. Which one is at highest priority for the nurse to follow
up?
1. An above-knee amputation client discharge with crutches yesterday called for arms edema and numbness.
2. A gastric cancer client discharged with intravenous tube
insertion 2 days ago complained infiltration around insertion side.
3. A fractured client with traction about home called that the rope of the traction is broken.
4. A mother of a 4-month infant with infant apnea syndrome told
the nurse that the alarm of Respiratory monitor did not work well.
這個題目中的病人都帶有不同的醫療器械。第一個病人上肢的水腫麻木,很有可能是拐杖使用不當或者不合適,需要糾正調整。這是一個有關
peripheral circulation的狀況。第二個病人保留針頭外滲,也是一個peripheral
circulation的狀況。第三個病人的牽引的繩子斷了,需要幫助修復,否則影響骨折的恢復,但是這個情況并不致命。第四個病人因為有呼吸停止綜合
征,所以需要使用monitor all the
time,并且一定要有報警裝置,報警時一定要立即檢查嬰兒的呼吸情況。現在報警裝置出問題了,雖然嬰兒本身可能還沒有出現呼吸停止,但是仍然非常危險,
所以要先解決。因此這個題的選項應該是4。